Purpose: To retrospectively analyze clinical outcomes of patients with "treatment-resistant" neovascular age-related macular degeneration or diabetic macular edema who were switched to intravitreal faricimab injections (IFIs) using a "real-world" treat-and-extend (TAE) protocol. Methods: Seventy-one eyes from 62 patients receiving antivascular endothelial growth factor injections were evaluated before and after switching to IFI. Demographic and clinical data were collected. Primary endpoints were treatment interval extension and presence of intraretinal or subretinal fluid on spectral-domain optical coherence tomography (OCT) after switching to IFI. Secondary endpoints included best-corrected visual acuity, average OCT central subfield thickness, and presence of a pigment epithelium detachment and pigment epithelium detachment height. Results: The average treatment interval after switching to IFI significantly increased from 37.6 ± 10.8 days to 45.2 ± 16.6 days (p = 0.0016). At the last follow-up, 35% of eyes were able to achieve a fluid-free status post-IFI. A chi-square test of independence validated this finding by showing a significant difference in the OCT findings trending towards less or no fluid on follow-up (X 2 [3, N = 71] = 13.0705; p = 0.0003). The average central subfield thickness decreased from 327.2 ± 89.1 μm to 294.8 ± 86.5 μm (p = 0.0294). Best-corrected visual acuity, intraocular pressure, pigment epithelium detachment presence, and height had no significant difference after switching to IFI. Conclusions: In "treatment-resistant" patients receiving anti-VEGF therapy for neovascular age-related macular degeneration or diabetic macular edema, switching to IFI in a "real-world" TAE protocol led to statistically significant improvements in treatment interval and retinal fluid on spectral domain OCT.

Sjögren-Larsson syndrome (SLS) is a rare, autosomal recessive neurocutaneous disorder. It is caused by the inheritance of sequence variants in the ALDH3A2 gene, which codes for fatty aldehyde dehydrogenase (FALDH). Universal signs of the condition are congenital ichthyosis, spastic paresis of the lower and upper limbs, and reduced intellectual ability. In addition to this clinical triad, patients with SLS experience dry eyes and decreased visual acuity caused by a progressive retinal degeneration. Examination of the retina in patients with SLS often reveals glistening yellow crystal-like deposits surrounding the fovea. This crystalline retinopathy often develops in childhood and is considered pathognomonic for the disease. The metabolic disorder typically shortens lifespan to half that of the unaffected population. However, now that patients with SLS live longer, it becomes increasingly important to understand the natural course of the disease. Our case describes a 58-year-old woman with advanced SLS whose ophthalmic examination illustrates the end-stage of the retinal degeneration. Optical coherence tomography (OCT) and fluorescein angiography confirm the disease is restricted to the neural retina with dramatic thinning of the macula. This case is unique since it is among the most advanced both in terms of chronological age and severity of retinal disease. While the accumulation of fatty aldehydes, alcohols, and other precursor molecules is the probable cause of retinal toxicity, a more complete understanding of the course of retinal degeneration may aid in the development of future treatments. The aim of our presentation of this case is to increase awareness of the disease and to foster interest in therapeutic research which may benefit patients with this rare condition.

Purpose The COVID-19 pandemic had a disproportionate impact on patients from racial and/or ethnic minority groups, causing many to delay healthcare. This study evaluates the role telehealth visits played in helping patients with diabetes mellitus (DM) return for subsequent, in-person eye examinations after the outbreak of COVID-19. Methods This retrospective, cross-sectional study analyzed 8147 patients with DM who had completed an outpatient ophthalmology and/or optometry visit in 2019 and who were due for return evaluation after the outbreak of COVID-19 in 2020. Factors associated with return for subsequent, in-person eye examination were assessed. Results The mean age of patients was 68.8 (±13.0) years, and 42% were women. 7.4% of patients identified as Asian; 2.9% as Black; 3.4% as Hispanic or Latin American; 0.92%, as more than one race; 1.78%, as other races; and 80.7% as White. Patients from racial and/or ethnic minority groups completed fewer in-person eye examinations after the outbreak of COVID-19 compared with White patients (35.6% versus 44.5%, χ2=36.172, P<0.001). However, both groups accessed telehealth services at a similar rate during this period (21.1% versus 21.9%, χ2=0.417, P=0.518). Importantly, patients who received telehealth services returned for subsequent, in-person eye examinations at substantially higher rates, regardless of race (51.0% and 46.6%, respectively, χ2=1.840, P=0.175). This offset the otherwise lower rate of return experienced by patients from racial and/or ethnic minority groups compared with White patients among the group of patients who did not receive any telehealth services (32.7% versus 42.7%, χ2=36.582, P<0.001). The impact of telehealth on the likelihood of in-person return remained significant after taking into account age, gender, race, language, residence, severity of diabetic retinopathy (DR), and vision in a multivariate model. Conclusion Telehealth initiatives benefited patients from racial and/or ethnic minority groups by reducing disparities in access to eye care experienced during the COVID-19 pandemic.

Purpose : The aim of this study is to determine whether telehealth (TH) appointments improve the rate of return for in-person diabetic eye exams. Methods : A retrospective chart review was conducted to determine the rate of return for in-person diabetic eye examinations for patients with diabetes who had been seen in the Department of Ophthalmology at the Lahey Hospital & Medical Center in 2019. Since TH appointments were not initiated at the Lahey Hospital & Medical Center until March 16, 2020 in response to the COVID-19 pandemic, this study looked at only patients who were seen after this date. The main outcome was the number of in-person diabetic eye exams completed by patients who had a prior TH encounter compared with those that did not have a TH encounter. Patient demographic (age, gender, ethnicity, and race) and clinical characteristics (A1c, type of diabetes, and severity of retinopathy) were abstracted from the medical record. Results : Of the 7,796 patients with a diagnosis of diabetes who were seen in 2019, 1,723 (22.1%) completed TH appointments in 2020. The rate of return for in-person diabetic eye examinations was significantly greater for the cohort of patients who completed a TH appointment compared with those who did not (44.6% compared with 36.5%, OR: 1.71 95% CI: 1.54 - 1.90, p<0.0001). Patients with diabetic retinopathy were more likely to complete a TH visit. Of the 1,202 patients with diabetic retinopathy, 365 patients (30.4%) competed a TH appointment. In contrast, only 1,294 of the 5,999 patients (21.6%) without a history of retinopathy competed a TH appointment (χ =43.693, p <0.0001). For both groups the likelihood that a patient would subsequently complete an in-person diabetic eye exam increased after the completion of a TH encounter: 74% of patients with diabetic retinopathy completed an in-person visit after a TH appointment, compared with 49.6% of patients who returned for in-person care without a prior TH appointment (OR: 2.89;95% CI: 2.20 - 3.79, p<0.0001). Similarly, 44.6% of patients without retinopathy who completed a TH visit returned for in-person care, compared with only 36.5% who did not complete a TH visit (OR: 1.40;95% CI: 1.24 - 1.59, p<0.0001). Conclusions : TH appointments are an effective method to improve the likelihood that patients with diabetes and diabetic retinopathy will return for recommended in-person care.

PURPOSE:We conducted a cross-sectional study to assess the utilization of a tele-ophthalmology screening program in a low-risk, suburban population of patients with diabetes.METHODS:A total of 214 diabetic patients without previously documented diabetic retinopathy (DR) underwent point-of-care non-mydriatic fundus photography through their primary care providers at five Beth Israel Lahey Health locations. The characteristics of the patients who received remote screening were compared with those patients who were eligible for screening but did not take part in the program. Time-driven activity-based costing (TDABC) was implemented to examine the cost of screening by tele-ophthalmology compared with in-person examinations.RESULTS:Tele-ophthalmology screening was more likely to be provided for patients who were younger (OR 0.985; 95% CI 0.973-0.997, p=0.016), who were obese (OR 2.04; 95% CI: 1.47-2.84, p=0.008), who had an HbA1c above 8.0% (OR 1.60; 95% CI: 1.13-2.26, p=0.031), or who had an eye examination in the past year (OR 5.55; 95% CI: 3.89-7.92, p<0.001). Those patients newly diagnosed with DR because of the program were more likely to have diabetic nephropathy (OR 7.79; 95% CI: 1.73-35.05, p=0.007). TDABC identified a health system cost-savings of between $8 and $29 per patient screened by tele-ophthalmology compared with the cost of in-person eye examinations.CONCLUSION:Tele-ophthalmology presents an opportunity to reduce the costs of screening patients without prior evidence of DR, especially those who have completed a comprehensive eye examination within the prior year.

PURPOSE:To evaluate the functional and anatomic outcomes, as well as cost-effectiveness, of the timing of conversion to intravitreal aflibercept (IVA) in patients with treatment-resistant diabetic macular edema (DME).METHODS:Thirty consecutive eyes (25 patients) were identified that were treated with ≥3 intravitreal bevacizumab (IVB) and/or ranibizumab (IVR) injections prior to treatment with ≥3 IVA injections. Eyes that received ≤6 IVB and/or IVR injections (early-switch) were compared to those that received ≥7 injections (late-switch) prior to conversion to IVA. Treatment effectiveness was measured in quality-adjusted life years (QALYs). A micro-simulation model examined the impact of treatment duration on outcomes.RESULTS:Early- (n=18) and late- (n=12) switch eyes had similar vision prior to conversion to IVA. Despite improvements in retinal thickness, only the early-switch eyes maintained vision gains after conversion to IVA through the end of follow-up (p=0.027). Early switch saved $22,884/eye and produced an additional 0.027 QALYs.CONCLUSION:Early conversion to IVA optimizes vision outcomes and results in lower overall treatment expenditures.

*These authors contributed equally to this work Purpose: To evaluate the functional and anatomic outcomes, as well as cost-effectiveness, of the timing of conversion to intravitreal aflibercept (IVA) in patients with treatmentresistant diabetic macular edema (DME). Methods: Thirty consecutive eyes (25 patients) were identified that were treated with ≥3 intravitreal bevacizumab (IVB) and/or ranibizumab (IVR) injections prior to treatment with ≥3 IVA injections. Eyes that received ≤6 IVB and/or IVR injections (earlyswitch) were compared to those that received ≥7 injections (late-switch) prior to conversion to IVA. Treatment effectiveness was measured in quality-adjusted life years (QALYs). A micro-simulation model examined the impact of treatment duration on outcomes. Results: Early(n=18) and late(n=12) switch eyes had similar vision prior to conversion to IVA. Despite improvements in retinal thickness, only the early-switch eyes maintained vision gains after conversion to IVA through the end of follow-up (p=0.027). Early switch saved $22,884/eye and produced an additional 0.027 QALYs. Conclusion: Early conversion to IVA optimizes vision outcomes and results in lower overall treatment expenditures.

In 2006, the Hospital Consumer Assessment of Healthcare Providers and Systems survey became the nation’s “first national, standardized, publicly reported survey of patients’ perspectives of hospital care.” 1 Congressional RecordThe Patient Protection and Affordable Care Act. https://www.congress.gov/111/plaws/pub1148/PLAW-111pub1148.pdfDate: 2010 Date accessed: November 20, 2016 Google Scholar The Patient Protection and Affordable Care Act of 2010 tied such surveys directly to hospital reimbursement, 2 Congressional RecordThe Health Care and Education Reconciliation Act of 2010. https://www.gpo.gov/fdsys/pkg/PLAW-111pub1152/pdf/PLAW-111pub1152.pdfDate: 2010 Date accessed: November 20, 2016 Google Scholar making understanding what drives patient satisfaction critical for providers to maintain good patient relationships.

BACKGROUND AND OBJECTIVE:To evaluate effect of retinal fluid status at week 12 on visual and anatomic outcomes at week 52 in patients with neovascular age-related macular degeneration from the VIEW studies.PATIENTS AND METHODS:Post-hoc analysis included 1,465 eyes treated with intravitreal aflibercept (Eylea; Regeneron, Tarrytown, NY) 2 mg every 4 weeks (2q4) or every 8 weeks following three initial monthly injections (2q8) or ranibizumab (Lucentis; Genentech, South San Francisco, CA) 0.5 mg every 4 weeks (Rq4), which had known retinal fluid status at weeks 12 and 52.RESULTS:At 12 weeks, 512 (35%) eyes had fluid and 953 (65%) were fluid-free. Two hundred three (41.5%), 148 (29.8%), and 161 (33.5%) eyes had fluid in Rq4, 2q4, and 2q8, respectively. Best-corrected visual acuity (BCVA) change at week 52 from baseline was independent of retinal fluid status at week 12 or treatment assignment. Eyes were more likely to remain fluid-free at week 52 if absent of fluid at week 12.CONCLUSION:At week 52, 2q4, 2q8, and Rq4 improved BCVA independent of fluid status at week 12.

PURPOSE:To compare the change in anterior chamber flare after intravitreal injection of the anti-vascular endothelial growth factor agents bevacizumab, aflibercept, and ranibizumab.METHODS:Sixty-one eyes of 53 patients underwent intravitreal injection with anti-vascular endothelial growth factor medications for exudative age-related macular degeneration, diabetic macular edema, or retinal vein occlusion. There were a total of 26 eyes injected with bevacizumab, 14 eyes injected with aflibercept, and 21 eyes injected with ranibizumab. Anterior segment flare was measured with a laser flare meter (Kowa) before intravitreal injection and 1 day after injection. The change in flare was analyzed.RESULTS:The mean change in flare after 1 day was +2.5 photons per millisecond in patients who received bevacizumab, 0.0 photons per millisecond for aflibercept, and -0.2 photons per millisecond for ranibizumab. There was a statistically significant difference between the 3 medications (P = 0.006). Pairwise analysis of the change in flare showed a statistically significant difference between bevacizumab and ranibizumab (P = 0.002). The change in flare in patients who received aflibercept was not different from that in those who received bevacizumab (P = 0.08) or ranibizumab (P = 0.99).CONCLUSION:There was a statistically significant increase in flare after bevacizumab injection compared with ranibizumab. This difference was small and is not believed to be clinically significant. There was no statistical difference in the change in flare between aflibercept and the other medications, although the number of eyes in the aflibercept group was small.

The frequency of musculoskeletal disorders (MSD) has been reported in the ophthalmic literature over the last decade.1Dhimitri K.C. McGwin Jr, G. McNeal S.F. et al.Symptoms of musculoskeletal disorders in ophthalmologists.Am J Ophthalmol. 2005; 139: 179-181Abstract Full Text Full Text PDF PubMed Scopus (74) Google Scholar, 2Chams H. Mohammadi S.F. Moayyeri A. Frequency and assortment of self-reported occupational complaints among Iranian ophthalmologists: a preliminary survey.MedGenMed. 2004; 6: 1PubMed Google Scholar, 3Chatterjee A. Ryan W.G. Rosen E.S. Back pain in ophthalmologists.Eye. 1994; 8: 473-474Crossref PubMed Scopus (42) Google Scholar, 4Sivak-Callcott J.A. Diaz S.R. Ducatman A.M. et al.A survey study of occupational pain and injury in ophthalmic plastic surgeons.Ophthal Plast Reconstr Surg. 2011; 27: 28-32Crossref PubMed Scopus (57) Google Scholar Based upon different criteria, survey instruments, and populations studied, the prevalence of MSD symptoms in ophthalmologists varies. Kitzmann et al5Kitzmann A.S. Fethke N.B. Baratz K.H. et al.A survey study of musculoskeletal disorders among eye care physicians compared to family medicine physicians.Ophthalmology. 2012; 119: 213-220Abstract Full Text Full Text PDF PubMed Scopus (49) Google Scholar report the first study that compares MSD symptoms in ophthalmologists to family medicine doctors at 2 institutions using the same survey instrument. Ophthalmologists reported a statistically significant increased prevalence of neck, hand/wrist, and lower back pain in comparison to their family medicine doctor colleagues. Although the number of ophthalmologists surveyed was relatively low, and findings in practice settings as opposed to these 2 academic institutions may differ, the rates of symptoms among ophthalmologists were comparable to a survey done almost a decade ago in a larger cohort of subjects.1Dhimitri K.C. McGwin Jr, G. McNeal S.F. et al.Symptoms of musculoskeletal disorders in ophthalmologists.Am J Ophthalmol. 2005; 139: 179-181Abstract Full Text Full Text PDF PubMed Scopus (74) Google Scholar In response to published reports and data from the recent American Academy of Ophthalmology (AAO) membership survey (private communication, AAO Membership Secretariat, April 2010), the AAO Board of Trustees has commissioned a task force composed of 6 ophthalmologists, a group of ergonomics specialists headed by Dr. Sandra Woolley from the Mayo Clinic, and representatives from AAO leadership. Our goals are: (1) to inform academy members about common occupational musculoskeletal disorders and how to prevent them, and (2) to develop ergonomic guidelines/standards for ophthalmic equipment and encourage their adoption by the device industry. The National Institute of Occupational Safety and Health (NIOSH) have identified 4 factors influencing the development of musculoskeletal disorders: (1) environmental hazards, (2) human biologic factors, (3) behavioral factors or unhealthy lifestyles, and (4) inadequacies in existing health care.6NIOSH: Proposed national strategies for the prevention of leading work-related diseases and injuries. Association of Schools of Public Health, Cincinnati, OH1986Google Scholar As work-related MSDs are the result of multiple causes, only some of which may be modifiable, ergonomic intervention alone may not eliminate the risk or decrease the symptoms. However, to effectively manage these problems, it is important to understand all of the factors including age, presence of systemic disease, physiologic predisposition, work behaviors, type of job, and ergonomic design of equipment.7Gassett R.S. Hearne B. Keelan B. Ergonomics and body mechanics in the work place.Orthop Clin North Am. 1996; 27: 861-879PubMed Google Scholar Musculoskeletal disorders in health professionals have been extensively documented. By far the largest body of work related to MSDs and health care professionals is in the dental and laparoscopic surgery fields. While we undertake efforts in ophthalmology to identify risk factors, educate membership, and work with industry to adapt equipment, we can use the other medical specialties' experiences to glean several relevant take home lessons for ophthalmologists and our task force. Exposure to risks for MSDs starts early and attention to ergonomic recommendations need to occur during training. Several studies have shown that dental and dental hygiene students report significant and increasing upper extremity and back pain that extend into their practicing years.8Morse T. Bruneau C. Michalak-Turcotte C. et al.Musculoskeletal disorders of the neck and shoulder in dental hygienists and dental hygiene students.J Dent Hyg. 2007; 81: 10PubMed Google Scholar Although the prevalence may be lower than in older, more experienced practitioners, studies suggest that prevention programs should be introduced in training programs. In a study of practicing laparoscopic surgeons, those who were self-reported as "very aware" of ergonomic recommendations and strategies obtained this information during their surgical training.9Park A. Lee G. Seagull F.J. et al.Patients benefit while surgeons suffer: an impending epidemic.J Am Coll Surg. 2010; 210: 306-313Abstract Full Text Full Text PDF PubMed Scopus (312) Google Scholar Surgeons also acquired their knowledge from the literature, as well as regional or national meetings. Grand rounds presentations were the least likely source of ergonomic knowledge. Across all medical specialties, patient volume seems to have the highest correlation with prevalence of musculoskeletal symptoms. In a survey of 317 surgeons identified as involved in laparoscopic practices, almost 87% reported physical symptoms of discomfort.9Park A. Lee G. Seagull F.J. et al.Patients benefit while surgeons suffer: an impending epidemic.J Am Coll Surg. 2010; 210: 306-313Abstract Full Text Full Text PDF PubMed Scopus (312) Google Scholar The strongest predictor of symptoms was high case volume and was little related to age, height, or duration in practice. The authors point out that the stresses of surgery need not discriminate beyond young and old; if a surgeon performs a sufficient volume of cases, he or she is likely to suffer symptoms. This correlates with a survey performed at our institution with 697 ophthalmologists responding in the northeast United States where age was not a risk for the self-reporting prevalence of MSD symptoms. Seeing more than 100 patients per week, performing ≥4 surgeries and/or ≥6 lasers/week were associated with increased risks of neck, upper extremity, or lower back symptoms.1Dhimitri K.C. McGwin Jr, G. McNeal S.F. et al.Symptoms of musculoskeletal disorders in ophthalmologists.Am J Ophthalmol. 2005; 139: 179-181Abstract Full Text Full Text PDF PubMed Scopus (74) Google Scholar However, with financial pressures and declining reimbursements mounting, it is unlikely that we can reasonably expect ophthalmologists to reduce their clinical volumes to reduce the likelihood of injury. Fortunately, there is evidence to suggest that will not be necessary. In a time-motion study of dentists, patient height positioning was expected to take 5 seconds, but on average dentists took approximately 3 seconds to position the patient. For just 2 extra seconds per patient, the dentist could have positioned the patient in a more optimal height position.10Dougherty M. Ergonomic Principles in the dental setting. June 2001 Thomson Healthcare/Dental Products Report.Google Scholar Many ergonomic interventions do not take a lot of physician time. Ergonomic intervention may result in increased ability to maintain or increase work time. In another study of dentists undergoing ergonomic intervention, 72% reported their first-mentioned or only complaint diminished or disappeared, 58% that their second-mentioned complaint disappeared or diminished, and 64% their third mentioned complaint diminished or disappeared.11Droeze E.H. Jonsson H. Evaluation of ergonomic interventions to reduce musculoskeletal disorders of dentists in the Netherlands.Work. 2005; 25: 211-220PubMed Google Scholar In that same study, the mean working hours before the complaint was 34 hours per week, and before ergonomic intervention was 24 hours per week. Although the mean hours stayed the same after intervention, 30% had an increase in work hours and 45% remained stable. In the group without change, dentists reported they could now work 24 hours per week without pain. The demands on ophthalmologists are changing. Increasing patient volume, transitions to electronic medical records, and changing procedures may represent barriers to reducing ergonomic risk factors. Designing the ophthalmic lane with multiple monitors for maximum electronic medical record performance, while maintaining the relationship with the patient creates new ergonomic challenges for ophthalmologists and ancillary support staff. Improving the ergonomics of ophthalmic delivery will require changes in instrument design, operator skill, and perhaps the redesign of the ophthalmic lane and operating room. The number and design of instruments, devices, microscopes, and other equipment compounded by the many types of procedures performed make changes even more complicated. However, one should not discount even the smallest changes as they can have a profound effect. For example, in dentistry increasing the angle of the prevailing dental mirror surface to its handle by 7 degrees reduces the habit of laterally extending the elbow of the arm holding the mirror.10Dougherty M. Ergonomic Principles in the dental setting. June 2001 Thomson Healthcare/Dental Products Report.Google Scholar Equipment manufacturers have begun to respond to the ergonomic challenges of ophthalmic practice and are introducing tilted ocular for slit lamps, extenders for surgical operating microscopes, and 3-dimensional virtual surgery. The article by Kitzmann et al5Kitzmann A.S. Fethke N.B. Baratz K.H. et al.A survey study of musculoskeletal disorders among eye care physicians compared to family medicine physicians.Ophthalmology. 2012; 119: 213-220Abstract Full Text Full Text PDF PubMed Scopus (49) Google Scholar confirms what many of us already believed. The awkward postures, long static positions resulting in prolonged muscle contractions, and lack of attention to ergonomic issues are associated with higher rates of musculoskeletal symptoms in ophthalmologists compared with a family medicine control group. Although the costs of resetting the ophthalmic lane and operating room may be high, they probably are one-time expenses. The benefits to providers and patients are presumably ongoing and likely more significant. A Survey Study of Musculoskeletal Disorders Among Eye Care Physicians Compared with Family Medicine PhysiciansOphthalmologyVol. 119Issue 2PreviewTo evaluate the prevalence of musculoskeletal disorders among eye care physicians compared with family medicine physicians. Full-Text PDF

Blaha, Gregory R MD, PhD; Tilton, Elisha P MD; Barouch, Fina C MD; Marx, Jeffrey L MD Author Information